Psychiatric Emergency Department: Where Treatment Should Begin

The most common request Jon Berlin, M.D., hears in his work in the psychiatric emergency department is: "Doc, get me the [bleep] outta here."

Credit: Aaron Levin

"Good," Berlin tells the patient. "It's my job to get that started."

In fact, his job is not to just get the patient out the door or admitted, but to make the emergency department encounter the beginning of treatment, he explained at APA's 2011 annual meeting in Honolulu in May (see What Patients Want From Emergency Care).

Berlin is medical director of the crisis service at the Milwaukee County Behavioral Health Division and an associate clinical professor of psychiatry at the Medical College of Wisconsin. He estimates he has overseen care for about 150,000 emergency psychiatric patients since 1997.

"My goal is to turn an acute-care emergency patient into an outpatient," he declared.

Facing an acutely symptomatic patient is not a normal experience, and it takes some mental preparation, said Berlin. Between 20 percent and 50 percent of psychiatric emergency patients are at risk for agitation, and up to 10 percent may be actively agitated or violent during the evaluation, he noted.

"Everybody wants someone else to talk to that person," he said. "Your first reaction is to freeze, so you must prepare yourself emotionally to engage the patient."

Patient encounters should include checking vital signs and ruling out possible general medical causes for the behavior that brought the patient into the hospital.

Once that is completed, the psychiatrist should begin by thinking through the reasons for noncoercive engagement, he said.

Keeping the hospital's seclusion and restraint rates low is one such reason. Creating a therapeutic alliance is another. Because patients see coercion as a form of violence, avoiding coercion as much as possible is a way to model nonviolent treatment and thus increase engagement and reduce recidivism, he pointed out.

Berlin approaches agitated patients carefully, with a security guard standing in the background, and tries to use cognitive techniques to calm the patient.

"There's a place and a time for roaring, but not here and now," he'll tell a disruptive patient. "Can we talk...?"

He'll try starting a discussion of possible medications, based on the patient's history and preferences.

"Don't push meds and don't delay meds," he said.

However, giving a depot shot of a drug is unethical, because it amounts to committing the patient to a specific long-term treatment, he said.

Suicidality Presents Unique Challenges

Patients presenting with suicidal ideation can be hard to read. "Sometimes you can end an interview without knowing if you've got an accurate suicide report," he said.

One starting point for judging the authenticity of suicidal ideation is to figure out "why now?"

"Search for the underlying crisis state of mind at the time of peak suicidality," suggested Berlin. "Walk them through that day. What triggered their loss of perspective?"

Expect resistance to talking about emotionally charged issues surrounding suicidality, he said. The patient may have had a bad experience with caregivers, fear being misunderstood, or believe that the evaluator can't handle his or her problems. Others may fear being locked up, although suicidal ideation alone is not a sufficient reason to place a patient on a locked ward.

Much More Than an Intake Ward

Psychiatric emergency departments have become de facto gateways into mental health systems, said fellow panelist Scott Zeller, M.D., chief of psychiatric emergency services at the Alameda County Medical Center in Oakland, Calif. Zeller is the president of the American Association for Emergency Psychiatry.

The old psychiatric emergency room was too often simply the intake ward for the hospital, used only for triage and referral, said Zeller. The modern emergency department is still a place for triage and referral, but also for treatment.

Early engagement and treatment decrease length of stay in the emergency department or the hospital. About 78 percent of his patients are admitted or go home or to an outpatient clinic within 24 hours, said Zeller.

Ultimately, a safe admission can begin the process of going home, said Berlin.

"Help the patient calm himself; otherwise, he'll never learn how to do it," Berlin said. Self-restraint leads to less physical (or pharmacological) restraint, triage leads to treatment, and treatment with respect leads to engagement and collaboration, he suggested. Be authoritative but not authoritarian; collaborate without abdicating expertise, but recognize the inherent limitations in the process.

"Accept the fact that you'll make mistakes in the rush," he emphasized. "Afterward, go back over the process with your team and learn from your mistakes. And remember that there will be some people you cannot de-escalate without coercion."

The message to get across to the patient is, he said: "We need to see that it's safe for you to go. Show us. Start now. You've made a great start."